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Background: Distal radius fractures (DRFs) are one of the most common major fractures. Despite their frequency, the tradeoffs in different outcomes after casting or surgery for closed extraarticular DRFs in older adults are unknown.Questions/purposes: (1) For adults older than 60 years with closed extraarticular DRFs, what are the tradeoffs in outcomes for choosing casting versus surgery? (2) In what settings would surgery be preferred over casting?Method: This is a secondary analysis of data from the Wrist and Radius Injury Surgical Trial (WRIST), a randomized, multicenter clinical trial that enrolled patients from April 10, 2012 to December 31, 2016. For WRIST, researchers recruited patients older than 60 years who sustained closed extraarticular distal radius fractures from 24 sites in the United States, Canada, and Singapore. We conducted a secondary analysis using data from WRIST, which had longitudinal data from a robust collection of covariates for patients who underwent surgery and casting. Among the 296 patients recruited in the WRIST study, 59% (174) of patients (mean age 71 ± 9 years) with complete sociodemographic data and 12-month follow-up for each primary outcome were included in the main analysis. More patients underwent surgery than casting (72% [126 of 174] versus 28% [48 of 174]). Most sociodemographic variables were similar between the surgery and casting groups, except for age and volar tilt. The surgical cohort was composed of patients randomized to external fixation, closed reduction percutaneous pinning, or volar locking plate internal fixation. The casting cohort consisted of patients who elected to be treated with closed reduction and casting. A tree-based reinforcement statistical learning method was used to determine the best treatment, either surgery or casting, to maximize functional and esthetic outcomes while minimizing pain. Tree-based reinforcement learning is a statistical learning method to build an unsupervised decision tree within a causal inference framework that will identify useful variables and their cutoff values to tailor treatment assignment accordingly to achieve the best health outcome desired. The primary outcome was minimization of pain (12-month Michigan Hand Outcomes Questionnaire pain subdomain score), maximization of grip strength, total ROM (supination and wrist arc of motion), and esthetics (12-month Michigan Hand Outcomes Questionnaire esthetics subdomain score).Results: Casting was the best treatment to reduce pain and maximize esthetics, whereas surgery maximized grip strength and ROM. When the patient favored gaining ROM over pain reduction (more than 80:20), surgery was the preferred treatment. When the patient prioritized the importance of grip strength over pain reduction (more than 70:30), surgery was also the preferred treatment.Conclusion: There are tradeoffs in outcomes after treating patients older than 60 years with closed extraarticular distal radius fractures with casting or surgery. When patients are attempting to balance minimizing pain and improving functional outcomes, unless they desire maximal functional recovery, casting may be the better treatment. Surgery may be beneficial if patients want to regain as much grip strength and ROM as possible, even with the possibility of having residual pain. These findings can be referenced for more concrete preoperative counseling and patient expectation management before treatment selection.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background  The use of the venous flap for simultaneous revascularization and coverage of soft tissue defects has been documented in the literature for over 30 years. First described in 1981, Nakayama et al demonstrated that a vein and overlying skin, or a venous flap, may be transposed from one area of the body to another with complete survival of the graft. The aim of this study was to conduct a systematic review of the literature to determine predictors of venous flap survival in traumatic hand injuries. Methods  A literature search of PubMed, MEDLINE, and Cochrane Library was performed with emphasis on venous flap use in traumatic hand injuries. MeSH terms included: vein graft, revascularization, venous flow through flap, arterialized venous flap, bypass, replantation, amputation, avulsion, trauma, injury, amputate, finger, hand, and thumb. Results  Forty-three articles were collected that contained data on 626 free venous flaps. Most patients were males (73.9) and injured their right hand (52.3%). The forearm was the most commonly used venous flap donor site (83.6%), and most of the skin paddles were 10 to 25 cm 2 (41.1%). Arterial inflow was used in 93.1% of the flaps. Most venous flaps (79.6%) healed without superficial tissue loss or necrosis. Ninety-two (14.7%) flaps had partial loss while 36 (5.8%) flaps did not survive. Conclusion  The use of venous flaps for concomitant revascularization and soft tissue coverage of the hand permits good results with limited morbidity. The overall flap survival rate is nearly 95%. Younger patients whose flaps have arterial inflow and skin paddles of medium size (10–25 cm 2) have the best chance for survival. [ABSTRACT FROM AUTHOR]

Introduction: Autologous breast reconstruction remains a popular surgical option following mastectomy; however, it is not without complications. Preoperative CT angiograms (CTAs) are often obtained for surgical planning, and morphometric data such as fat and muscle distribution can be measured. This study aimed to assess if CTA morphometric data predicts abdominal donor site complications in patients undergoing abdominally based autologous breast reconstruction. Methods: A retrospective cohort study was performed for patients who underwent abdominally based autologous breast reconstruction from 2013 to 2018. Along with population and operative characteristics, preoperative morphometric variables were assessed for the following: subcutaneous adipose tissue, visceral adipose tissue, skeletal muscle area and index, rectus and psoas cross-sectional area, and bone density. Statistical comparison to abdominal donor site complications was performed using logistic regression analysis for every 100-unit change. Results: A total of 174 patients were included in this study. Visceral adipose tissue was significantly associated with the development of infection ( P  = .005), epidermolysis ( P  = .031), and seroma ( P  = .04). Subcutaneous adipose tissue, skeletal muscle index, cross-sectional muscle area, and bone density were not associated with abdominal donor site complications. Obesity ( P  = .024), history of smoking ( P  = .049), and the number of perforators harvested ( P  = .035) significantly increased the likelihood of delayed abdominal healing. Conclusions: This study demonstrates that increased visceral adipose tissue, as measured by CTA, is significantly associated with an increased risk of abdominal donor site complications. CTA morphometric data and identifying high-risk patient characteristics can help guide preoperative counseling and better inform surgical risks., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2022 The Author(s).)

Introduction: Drain placement is commonplace after many plastic surgery procedures to evacuate excess blood and fluid. Tranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease bleeding and fluid production at surgical sites and can be administered orally, intravenously, and topically. The purpose of this study is to evaluate the effect of topical TXA on drain removal in abdominally based autologous breast reconstruction (ABABR). Methods: A retrospective chart review was performed on patients who underwent ABABR from August 2018 to November 2019. In 1 cohort, a 2.5% TXA solution was topically applied to the abdominal wall prior to closure. Drains were removed when output was less than 30 mL/day for 2 consecutive days. The primary outcome was days to drain removal. Secondary outcomes include daily inpatient drain output, postoperative hemoglobin levels, blood transfusions, and complications within 30 days postoperatively. Results: Eighty-three patients were included, with 47 in the control group and 36 in the TXA group. Drains were removed significantly earlier in patients who received TXA (16 days vs 23 days, P  = .02). Additionally, significantly fewer patients required postoperative blood transfusions in the TXA group (2 vs 14, P  = .005). Abdominal complications were fewer in the TXA group with significantly less wound healing complications (22% vs 49%, P  = .01). There was no difference in flap loss or systemic thromboembolic events. Conclusion: Topical TXA use in ABABR results in earlier abdominal drain removal, less blood transfusions, and lower abdominal wound complications without an increased risk of flap loss or adverse patient outcomes., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2022 The Author(s).)

Introduction: Magnetic resonance imaging (MRI) for soft-tissue wrist injury may be overprescribed, contributing to ineffective health care resource use. We aimed to discern predictive factors that may improve MRI's application in soft-tissue wrist injury., Methods: We conducted a retrospective chart review of adults who underwent MRIs for possible soft-tissue wrist injury between June 2009 and June 2014. Clinical data and treatment recommendations before and after MRI were analyzed. If the MRI-directed treatment recommendation was different from before MRI, the MRI was noted to have influenced the patient's treatment (Impact MRI)., Results: Among 140 MRI scans, 39 (28%) impacted treatment recommendation. Twenty-six Impact MRIs were ordered by hand surgeons, whereas 13 were ordered by referring physicians ( P = .001). More Impact MRIs were found when an MRI was ordered for patients younger than 36 years ( P = .01), within 6 weeks of symptom onset ( P = .03), to question a specific anatomic injury ( P = .0001), or by a board-certified hand surgeon ( P = .001). Adjusting for other covariates, these 4 clinical factors were identified as independent predictive factors to Impact MRIs., Conclusions: MRIs for soft-tissue wrist injuries may more likely change management when the patient is younger, ordered within 6 weeks of symptom onset, and prescribed with a specific differential diagnosis. Referral to a hand surgeon should be considered before wrist MRI for the following patients: history of hand surgery/trauma, older than 36 years likely due to confounding chronic wrist changes, symptomatic for more than 6 weeks, and without clear differential diagnoses for the symptoms., Competing Interests: Conflict of interest: none declared., (© Copyright 2018 by the American Board of Family Medicine.)

After reviewing this article, readers should have a comprehensive understanding of the indications for diagnostic arthroscopy, technical considerations in performing a systematic evaluation of the wrist, and limitations of this technique., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Although the true incidence of scapholunate interosseous ligament (SLIL) injury is unknown, a study found that 35% of cadaveric wrists had some degree of scapholunate tear. Of those wrists with SLIL injury, 29% had evidence of arthrosis. Early recognition and treatment of these injuries can delay or prevent the onset of arthritis. This article details treatment options for SLIL injury across the spectrum of pathology with a particular emphasis on chronic scapholunate repair and reconstruction. New techniques and outcomes data also are presented., (Copyright © 2015 Elsevier Inc. All rights reserved.)

With a rise in tissue expander-based breast reconstructions (TEBRs) using acellular dermal matrix (ADM), we have seen an increase in ADM-specific complications. In this study, we aimed to evaluate clinically significant seroma (CSS) formation-defined by the need for a drainage procedure-to determine if there was a difference in incidence between product types: AlloDerm (AL), DermaMatrix (DM), and FlexHD (FHD). This was a retrospective review of consecutive patients who underwent TEBR at a single institution. The total number of reconstructed breasts was separated into the following 4 groups according to the product type: AL, DM, FHD, or no ADM. We identified the total number of CSSs and compared these data between product types. A logistic regression was performed in an attempt to identify independent risk factors associated with seroma formation. In total, we identified 284 consecutive TEBRs. Overall, there were 17 (7.7%) seromas in 220 breast reconstructions in which ADM was used. When comparing the number of CSS between groups-AL (n = 2, 4.0%), DM (n = 6, 5.4%), FHD (n = 9, 14.75%), and no ADM (n = 1, 1.5%)-we found a significant difference in seroma incidence between product types (P = 0.016). Multivariate analysis identified a strong trend toward FHD as an independent predictor of seroma formation (P = 0.061). Our review suggests that there is strong trend in CSS formation with the use of FHD as compared to other product types and reconstructions in which no ADM was used.